Medication high scores

[Coupd'Cat]

Adderall 30mg QID in the ED for someone who came in manic

Ativan 12mg daily (3mg QID) for a patient w/ history of catatonia

I inherited a few patients who had been on lexapro to 40mg for years, never having tried a second antidepressant or augmentation--still with depression. None of these patients had OCD.

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[brazilianpsych]

Adderall 30mg QID in the ED for someone who came in manic

Ativan 12mg daily (3mg QID) for a patient w/ history of catatonia

I inherited a few patients who had been on lexapro to 40mg for years, never having tried a second antidepressant or augmentation--still with depression. None of these patients had OCD.

But this was is very correct and not wrong. Guidelines often recommend trying up to 20-24mg/day. I've seen patients that were very severe and only fully improved with 18mg/day, and in those cases you really don't want to discontinue it before discharge.

I think I saw a halloo 80mg once time, that is probably the highest I've seen.

 

[Coupd'Cat]

But this was is very correct and not wrong. Guidelines often recommend trying up to 20-24mg/day. I've seen patients that were very severe and only fully improved with 18mg/day, and in those cases you really don't want to discontinue it before discharge.

I think I saw a halloo 80mg once time, that is probably the highest I've seen.

True--I am just contemplating the process of down-titration it on the outpatient side. Haven't come across much evidence base, open to papers/others' experience.

 

[Celexa]

True--I am just contemplating the process of down-titration it on the outpatient side. Haven't come across much evidence base, open to papers/others' experience.

Yeah there's no literature. If someone had a severe catatonia due to either primary psych or a medical condition that necessitated being discharged on high dose benzos, my approach is to go slow over months after treatment for the underlying condition has been addressed if possible. I have not seen these patients be at risk of use disorder. Ideally you also want to loop in a family member or two who can be a second set of eyes bc patients are often not aware of it when catatonia signs creep back in.

Some of these patients end up on some amount of chronic benzo (although usually a more normal dose) permanently and that's just what it is. One of the categories of patients where chronic benzos can be completely appropriate.

As a CL psychiatrist who is often the person putting patients on these high dose benzos during the inpatient stay, if they get discharged from medicine to home I always do try and get my note and contact info to the outpatient psychiatrist because we see these patients all the time but I know it's not routine in most practices.

 

[Mad Jack]

Adderall XR 60 mg morning/60 mg afternoon and Adderall IR 30 mg in the early evening, total dose 150 mg daily

 

[calvnandhobbs68]

Adderall XR 60 mg morning/60 mg afternoon and Adderall IR 30 mg in the early evening, total dose 150 mg daily

When you need to party 24 hours a day

 

[WVpsych]

10 years old on 18 mg total Risperidone… the kid was on the spectrum, and PCP was trying their best.. the kid was restless, running all the time (duh), and drove the staff crazy. Tapered down slowly, started a stimulant, and later a tiny dose of Abilify.. he was doing great.

This one makes me cringe... Adderall 80mg total (pt insisted on 10mg tabs). I refused, but I was a resident, and my attending said, “they have been on this dose for years”, still refused, and pt was transferred to that attending.

Another kid on the spectrum… vyvanse and Ritalin IR (don’t recall doses but mid doses). Zoloft, Wellbutrin, Depakote, and guanfacine (higher doses). I kept scratching my head about what to do (after discontinuing Ritalin, of course). Tapered off one by one, the kid ended up on Vyvanse, guanfacine, and Zoloft.


A 9 y/o with mild ID, anxiety and ADHD. Said that they were "hearing voices" after getting into a fight with their cousin... NP Dx: Schizophreniform, Risperidal 4mg. Discharge dx: Social anxiety, mild ID, ADHD. Concerta and Zoloft... and the kid was able to sit down, learn and read.

I have seen kids with clear ADHD on antipsychotics.. Seroquel 600mg stands out in my mind. The NP was telling me that it was the most challenging case they had. They did not listen to my advice (after they asked for it, and this is not someone I am supervising). I talked to their attending, and things went ok. GET THE KID ON A STIMULANT DAMMIT.

I can keep going on and on.

 

[forchinet121]

10 years old on 18 mg total Risperidone… the kid was on the spectrum, and PCP was trying their best.. the kid was restless, running all the time (duh), and drove the staff crazy. Tapered down slowly, started a stimulant, and later a tiny dose of Abilify.. he was doing great.

This one makes me cringe... Adderall 80mg total (pt insisted on 10mg tabs). I refused, but I was a resident, and my attending said, “they have been on this dose for years”, still refused, and pt was transferred to that attending.

Another kid on the spectrum… vyvanse and Ritalin IR (don’t recall doses but mid doses). Zoloft, Wellbutrin, Depakote, and guanfacine (higher doses). I kept scratching my head about what to do (after discontinuing Ritalin, of course). Tapered off one by one, the kid ended up on Vyvanse, guanfacine, and Zoloft.


A 9 y/o with mild ID, anxiety and ADHD. Said that they were "hearing voices" after getting into a fight with their cousin... NP Dx: Schizophreniform, Risperidal 4mg. Discharge dx: Social anxiety, mild ID, ADHD. Concerta and Zoloft... and the kid was able to sit down, learn and read.

I have seen kids with clear ADHD on antipsychotics.. Seroquel 600mg stands out in my mind. The NP was telling me that it was the most challenging case they had. They did not listen to my advice (after they asked for it, and this is not someone I am supervising). I talked to their attending, and things went ok. GET THE KID ON A STIMULANT DAMMIT.

I can keep going on and on.

Wait you’re allowed to just refuse a direct order from your attending? That’s interesting actually

 

[Mad Jack]

When you need to party 24 hours a day

Patient chief complaint was feeling tense and screaming loudly in public for no reason that they could discern. On my informing them it may be due to the high stimulant dose prescribed by their current provider (this was an emergency consult), I was informed by the patient, "that's what you doctors always ****ing say, it's the Adderall. **** you, it's not the Adderall."

 

[TheRightMedication]

Wait you’re allowed to just refuse a direct order from your attending? That’s interesting actually

Residents are doctors, I don't see why not. There could be hell to pay socially and professionally, but clinically and ethically it's fine in my opinion.

 

[Merovinge]

This one makes me cringe... Adderall 80mg total (pt insisted on 10mg tabs). I refused, but I was a resident, and my attending said, “they have been on this dose for years”, still refused, and pt was transferred to that attending.

Super obviously diverting the script. I would actually be concerned they were cutting the attending in on it. No one is actually that stupid to send 240 10mg Adderall IRs a month. Very impressed you at least refused but I would definitely have discussed that case with another trusted attending/mentor to see what they thought.

 

[WVpsych]

Super obviously diverting the script. I would actually be concerned they were cutting the attending in on it. No one is actually that stupid to send 240 10mg Adderall IRs a month. Very impressed you at least refused but I would definitely have discussed that case with another trusted attending/mentor to see what they thought.

I left out lots of details intentionally. I did talk to one of my other attendings (who happens to be the director of the OP clinic). I included it as a supervision question more than a "questioning my attendings practice", and I knew they would ask me for details (which they did). The attending had previous incidents in terms of weird dosing and then blaming residents for not checking...

 

[forchinet121]

Residents are doctors, I don't see why not. There could be hell to pay socially and professionally, but clinically and ethically it's fine in my opinion.

You work under my license, you better do what I say..

 

[Mad Jack]

You work under my license, you better do what I say..

I've seen lives saved and lawsuits dodged by defying attendings that had concerning judgment. I also know a resident that ended up the primary defendant in a wrongful death lawsuit despite doing exactly what her attending told her to do (and knowing it was the wrong decision but also that he would never take no for an answer). In that state, residents are held to the standard of a physician within their field of practice and are the primary defendants in lawsuits, so you are co-practicing with an attending moreso than "practicing under their license."

 

[calvnandhobbs68]

You work under my license, you better do what I say..

Yeah no. A resident can certainly decline to do something that an attending requests them to do if they feel it's inappropriate or unethical (within reason) or possibly you know contributing to illegal activity (which something like giving prescriptions of 80mg adderall daily in 10mg increments is highly suspicious for). Since, as you alude to, the attending is the one with the supervisory license in that situation, the attending is then free to provide the care themselves.

This isn't the military bud and you aren't protected by sovereign immunity and chain of command like in the military.

 

[forchinet121]

Yeah no. A resident can certainly decline to do something that an attending requests them to do if they feel it's inappropriate or unethical (within reason) or possibly you know contributing to illegal activity (which something like giving prescriptions of 80mg adderall daily in 10mg increments is highly suspicious for). Since, as you alude to, the attending is the one with the supervisory license in that situation, the attending is then free to provide the care themselves.

This isn't the military bud and you aren't protected by sovereign immunity and chain of command like in the military.

I think you are actually though..as a resident you have an attending signing off on all your cases, if the attending was in the room and agreed with your treatment plan it is their license on the line and ultimately their decision..

 

[Celexa]

I think you are actually though..as a resident you have an attending signing off on all your cases, if the attending was in the room and agreed with your treatment plan it is their license on the line and ultimately their decision..

No. It is also your license. It is right and appropriate for a resident to decline to do something grossly unsafe, and if theres a good reason to do something atypical, it should for sure be something more than 'the patient has been on it forever', which is not a reason. As noted above, being a trainee is NOT protection from a lawsuit and the courts do not consistently view residents as non liable. They see a physician.

It's also worth noting that many residents, particularly in outpatient settings, moonlight and therefore are fully and independently licensed. Even if the courts viewed trainees consistently as absent of liability (which they very much do not) even that distinction is likely to be lost on a non-medical person when the resident is identifiably a fully licensed physician.

 

[TheRightMedication]

I think the technical medicolegal term for the attending-resident relationship is "liability buddies."

 

[Mad Jack]

I think you are actually though..as a resident you have an attending signing off on all your cases, if the attending was in the room and agreed with your treatment plan it is their license on the line and ultimately their decision..

This is highly dependent upon state law. In one state I practice in, it is correct. In another state, it is completely incorrect.

 

[forchinet121]

This is highly dependent upon state law. In one state I practice in, it is correct. In another state, it is completely incorrect.

Ok that’s good to know

 

[romanticscience]

1. Venlafaxine 375 qday
2. Escitalopram 40mg qday
3. Lamotrigine 400mg qday

1. Benkert, O., Gründer, G., Wetzel, H., & Hackett, D. (1996). A randomized, double-blind comparison of a rapidly escalating dose of venlafaxine and imipramine in inpatients with major depression and melancholia. Journal of psychiatric research, 30(6), 441-451.
2. Qi, W., Gevonden, M., & Shalev, A. (2017). Efficacy and tolerability of high-dose escitalopram in posttraumatic stress disorder. Journal of clinical psychopharmacology, 37(1), 89.
3. Concurrent OCP containing progesterone.

 

[forchinet121]

1. Venlafaxine 375 qday
2. Escitalopram 40mg qday
3. Lamotrigine 400mg qday

1. Benkert, O., Gründer, G., Wetzel, H., & Hackett, D. (1996). A randomized, double-blind comparison of a rapidly escalating dose of venlafaxine and imipramine in inpatients with major depression and melancholia. Journal of psychiatric research, 30(6), 441-451.
2. Qi, W., Gevonden, M., & Shalev, A. (2017). Efficacy and tolerability of high-dose escitalopram in posttraumatic stress disorder. Journal of clinical psychopharmacology, 37(1), 89.
3. Concurrent OCP containing progesterone.

All at once?

 

[clausewitz2]

1. Venlafaxine 375 qday
2. Escitalopram 40mg qday
3. Lamotrigine 400mg qday

1. Benkert, O., Gründer, G., Wetzel, H., & Hackett, D. (1996). A randomized, double-blind comparison of a rapidly escalating dose of venlafaxine and imipramine in inpatients with major depression and melancholia. Journal of psychiatric research, 30(6), 441-451.
2. Qi, W., Gevonden, M., & Shalev, A. (2017). Efficacy and tolerability of high-dose escitalopram in posttraumatic stress disorder. Journal of clinical psychopharmacology, 37(1), 89.
3. Concurrent OCP containing progesterone.

I've had a patient who I have had on 600 mg of lamotrigine for a time. Granted, this was someone with a planned pregnancy for whom we had a pre-pregnancy lamotrigine level at 300 mg for precisely this purpose, who got titrated to this dose to keep the level relatively steady during her pregnancy and cut back shortly thereafter, but still, not ridiculous in the right circumstances.

 

[romanticscience]

All at once?

No! Each a different patient.

 

[forchinet121]

No! Each a different patient.

Then that looks standard..

 

[aim-agm]

Buspirone 60 mg BID (TDD 120 mg)

Patient with GAD, excoriation disorder, and related conditions. Maxed on appropriate/indicated meds, and we had buspirone at 30 BID which had shown good and dose-dependent response to that point. Uptitrated slowly by increments of 5 mg BID with further improvement at each increment and no adverse effects. Stopped at 60 mg BID because (a) symptoms were finally reasonably well controlled on that dose, and (b) I wasn't courageous enough to more than double the usual maximum dose despite the excellent efficacy and tolerability.

 

[forchinet121]

Buspirone 60 mg BID (TDD 120 mg)

Patient with GAD, excoriation disorder, and related conditions. Maxed on appropriate/indicated meds, and we had buspirone at 30 BID which had shown good and dose-dependent response to that point. Uptitrated slowly by increments of 5 mg BID with further improvement at each increment and no adverse effects. Stopped at 60 mg BID because (a) symptoms were finally reasonably well controlled on that dose, and (b) I wasn't courageous enough to more than double the usual maximum dose despite the excellent efficacy and tolerability.

What we’re you afraid of with a dose increase

 

[clausewitz2]

Buspirone 60 mg BID (TDD 120 mg)

Patient with GAD, excoriation disorder, and related conditions. Maxed on appropriate/indicated meds, and we had buspirone at 30 BID which had shown good and dose-dependent response to that point. Uptitrated slowly by increments of 5 mg BID with further improvement at each increment and no adverse effects. Stopped at 60 mg BID because (a) symptoms were finally reasonably well controlled on that dose, and (b) I wasn't courageous enough to more than double the usual maximum dose despite the excellent efficacy and tolerability.

I should try this out sometime, it's not like we have anything else for excoriation disorder that actually works reliably.

 

[forchinet121]

I should try this out sometime, it's not like we have anything else for excoriation disorder that actually works reliably.

NAC?

 

[lol.psych]

I should try this out sometime, it's not like we have anything else for excoriation disorder that actually works reliably.

Maybe memantine?

 

[Stagg737]

NAC?

Meh, it’s an option but I wouldn’t call it reliable. Where I’m at I see a lot of people augment with an SGA for compulsions like excoriation. I was actually going to ask others on thoughts of adding buspar but looks like not a lot of experience with it here either.

 

[aim-agm]

What we’re you afraid of with a dose increase

Nothing specifically, although potentially as doses get higher an unexpected side effect might occur. There's also the element that the more you are off the beaten path, the worse it looks if something goes wrong, which gave me pause. If the patient's symptoms had improved but not adequately when we got to 60 BID, I would have tried some other late-line interventions, but if those didn't work I may have circled back to uptitrating buspirone futher.

I should try this out sometime, it's not like we have anything else for excoriation disorder that actually works reliably.

I'd be interested in your results. I can't say confidently if it was helping with the excoriation disorder per se, or just ameliorating the other conditions they had that were exacerbating the excoriation d/o. The patient also had other unusual neurological conditions which may theoretically have caused unusual features of their disorder or response to medications. But buspirone is benign enough that I feel its usually worth trying if it might work.

 

[calvnandhobbs68]

Maybe memantine?

Yeah there was that recent RCT for memantine in trichotillomania that was positive.